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Is quality of care during childbirth consistent from admission to discharge? A qualitative study of delivery care in Uttar Pradesh, India


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Background: Improving quality of maternal healthcare services is key to reducing maternal mortality across developing nations, including India. Expanding access to institutionalized care alone has failed to address critical quality barriers to safe, effective, patient-centred, timely and equitable care. Multi-dimensional quality improvement focusing on Person Centred Care(PCC) has an important role in expanding utilization of maternal health services and reducing maternal mortality. Methods: Nine public health facilities were selected in two rural districts of Uttar Pradesh(UP), India, to understand women's experiences of childbirth and identify quality gaps in the process of maternity care. 23 direct, non-participant observations of uncomplicated vaginal deliveries were conducted using checklists with special reference to PCC, capturing quality of care provision at five stages-admission; pre-delivery; delivery; post-delivery and discharge. Data was thematically analysed using the framework approach. Case studies, good practices and gaps were noted at each stage of delivery care. Results: Admission to maternity wards was generally prompt. All deliveries were conducted by skilled providers and at least one staff was available at all times. Study findings were discussed under two broad themes of care 'structure' and 'process'. While infrastructure, supplies and human resource were available across most facilities, gaps were observed in the process of care, particularly during delivery and post-delivery stages. Key areas of concern included compromised patient safety like poor hand hygiene, usage of unsterilized instruments; inadequate clinical care like lack of routine monitoring of labour progression, inadequate postpartum care; partially compromised privacy in the labour room and postnatal ward; and few incidents of abuse and demand for informal payments. Conclusions: The study findings reflect gaps in the quality of maternity care across public health facilities in the study area and support the argument for strengthening PCC as an important effort towards quality improvement across the continuum of delivery care.
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Is quality of care during childbirth consistent
from admission to discharge? A qualitative
study of delivery care in Uttar Pradesh, India
Malvika Saxena, Aradhana Srivastava, Pravesh Dwivedi, Sanghita BhattacharyyaID*
Research Department, Public Health Foundation of India, Gurugram, Haryana, India
Improving quality of maternal healthcare services is key to reducing maternal mortality
across developing nations, including India. Expanding access to institutionalized care alone
has failed to address critical quality barriers to safe, effective, patient-centred, timely and
equitable care. Multi-dimensional quality improvement focusing on Person Centred Care
(PCC) has an important role in expanding utilization of maternal health services and reduc-
ing maternal mortality.
Nine public health facilities were selected in two rural districts of Uttar Pradesh(UP), India, to
understand women’s experiences of childbirth and identify quality gaps in the process of
maternity care. 23 direct, non-participant observations of uncomplicated vaginal deliveries
were conducted using checklists with special reference to PCC, capturing quality of care
provision at five stages—admission; pre-delivery; delivery; post-delivery and discharge.
Data was thematically analysed using the framework approach. Case studies, good prac-
tices and gaps were noted at each stage of delivery care.
Admission to maternity wards was generally prompt. All deliveries were conducted by skilled
providers and at least one staff was available at all times. Study findings were discussed
under two broad themes of care ‘structure’ and ‘process’. While infrastructure, supplies and
human resource were available across most facilities, gaps were observed in the process of
care, particularly during delivery and post-delivery stages. Key areas of concern included
compromised patient safety like poor hand hygiene, usage of unsterilized instruments;
inadequate clinical care like lack of routine monitoring of labour progression, inadequate
postpartum care; partially compromised privacy in the labour room and postnatal ward;
and few incidents of abuse and demand for informal payments.
PLOS ONE | September 27, 2018 1 / 20
Citation: Saxena M, Srivastava A, Dwivedi P,
Bhattacharyya S (2018) Is quality of care during
childbirth consistent from admission to discharge?
A qualitative study of delivery care in Uttar Pradesh,
India. PLoS ONE 13(9): e0204607.
Editor: Alexandra Sawyer, University of Brighton,
Received: May 10, 2018
Accepted: September 11, 2018
Published: September 27, 2018
Copyright: ©2018 Saxena et al. This is an open
access article distributed under the terms of the
Creative Commons Attribution License, which
permits unrestricted use, distribution, and
reproduction in any medium, provided the original
author and source are credited.
Data Availability Statement: All relevant data are
within the paper and its Supporting Information
Funding: This work was supported by Grant
number - OPP1127467, URL - https://www. The funders had no role in
study design, data collection and analysis, decision
to publish, or preparation of the manuscript.
Competing interests: The authors have declared
that no competing interests exist.
The study findings reflect gaps in the quality of maternity care across public health facilities
in the study area and support the argument for strengthening PCC as an important effort
towards quality improvement across the continuum of delivery care.
In the past decade, maternal and newborn survival has been at the top of global health agenda,
and plays a crucial role in the overarching health goals of the Millennium Development Goals
(MDGs), and more recently, the Sustainable Development Goals 2030 (SDGs) [1]. As a result
of concentrated global advocacy and action focusing largely on increased access to institutional
care, the proportion of deliveries attended by skilled birth attendants in developing countries
rose from 57% in 1990 to 70% in 2014 [2]. However, this increase has not translated into the
desired reduction of maternal mortality, with an estimated 302, 000 deaths still occurring glob-
ally every year, almost 99 percent of which occur in lower and middle income countries [3].
Institutionalized care with increased access alone has failed to address the critical barriers in
providing quality care that is safe, effective, patient-centred, timely and equitable [4,5].
Quality of care (QoC) encompasses the dimensions of structure, process and outcome of
care, each aspect requiring equal emphasis for holistic improvement in QoC [68]. Person-
centered care (PCC) is a critical component of QoC, as it focuses on the care that is respectful
of and responsive to individual patient preferences, needs, and values and ensuring that patient
values guide all clinical decisions [7]. PCC has been addressed using different terminologies
such as patient, person, client, individual and are often used interchangeably in describing
health care [9]. Recently there has been a shift from a care that supports disease-centred care
to more on person-centred care where individuals are viewed as central to the decision making
process and are free to exercise their rights as patients. Whereas the former type of care focuses
primarily on the clinical aspect of the care giving less importance to other related aspects of
care like respect; dignity, privacy, confidentiality, informed choices etc [10,11]. PCC is crucial
for sustained utilization of maternal health services and to maximize health access and out-
comes, especially in contexts of socio-economic, ethnic and cultural diversities [12]. The recent
movement towards a composite approach in quality of maternity care has highlighted the need
for improving the experience of women as an important dimension, despite this aspect of care
being difficult to measure objectively [13]. The personal interaction between the woman and
provider is important in shaping her experience and perception of clinical care [14,15]. Wom-
en’s perspectives of maternity care that influenced their care-seeking behaviour ranged from
poor staff attitudes; lack of amenities; perceived poor quality of health care facilities. Other
reported barriers to effective utilization of maternity services were cost of care; poor access to
health facility and health services being not available at odd hours [1619]. Experience of ver-
bal and physical abuse, negative provider attitude, poor information sharing and lack of emo-
tional support from providers could be detrimental to utilization of maternity services [14,20].
In particular, India has witnessed a sharp surge in institutional delivery from 39% in 2005–
06 to 79% in 2015–16 with the implementation of the nationwide conditional cash transfer
program—Janani Suraksha Yojana (JSY) under the National Health Mission (NHM) in 2005
[21]. Despite this, reductions in maternal mortality have been limited [2124]. This is attrib-
uted to gaps in the clinical quality of facility-based maternal care [25,26]. Recent evidence also
points to women experiencing delays, neglect, abuse and poor client-provider communication
Quality of maternal care during childbirth in India
PLOS ONE | September 27, 2018 2 / 20
Abbreviations: CHW, Community Health Worker;
FHR, Fetal Health Rate; JSY, Janani Suraksha
Yojana; MDGs, Millennium Development Goals;
MIL, Mother-In-Law; MMR, Maternal Mortality
Ratio; MOIC, Medical Officer In-Charge; NHM,
Nation Health Mission; NMR, Neo-natal Mortality
Rat; PCC, Person Centred Care; PNC, Post-Natal
Care; QoC, Quality of Care; SDGs, Sustainable
Development Goals; UP, Uttar Pradesh; WHO,
World Health Organization.
during childbirth, leading to delayed care, and jeopardizing the likelihood of future utilization
of facility-based care [21,2730,31]. QoC in Indian policies and programs has fallen short at
addressing the quality gaps in providing care that is more responsive to patient’s needs and
ultimately leads to better outcomes [32,33].
Few studies have examined continuity of care and assessed women’s experiences through-
out her process of care. Consequently, we conducted direct, non-participant observations of
the process of maternity care as experienced by women delivering in public health facilities in
UP throughout their stay at the facility. The objective of the research was to understand the
quality of care that was provided to women during childbirth in health facilities and identify
associated gaps in the process of maternity care.
Materials and methods
We conducted 23 qualitative direct, non-participant observations of uncomplicated vaginal
deliveries in primary and secondary level public health facilities between October 2016 and
February 2017. After completing 23 observations data saturation was achieved and it was
decided to discontinue further data collection to avoid redundancy. The direct observation
approach helped in gaining first-hand, in-depth information on the quality of delivery care, in
addition to capturing complex and multiple patient-provider interactions.
Analytical framework
Our analysis is guided by Donabedian’s Quality framework and the World Health Organiza-
tion’s (WHO) Quality of Care Framework for maternal and newborn health [6,34]. The
results section is organised based on Donabedian framework of broad themes of care ‘struc-
ture’ and ‘process’. Donabedian defines Structure as the organisational and professional
resources associated with the provision of health care (e.g. staffing; facility infrastructure; avail-
ability of medicines and staff training) and Process as how the care is given ie the things done
to and for the patient (e.g. technical quality; experience of care). The WHO framework with its
eight domains of quality of care informed the sub-themes (Fig 1). Infrastructure refers to the
physical structures like buildings including arrangements for water and electricity, Human
resources refers to the number and configuration of hospital staff; their competency levels; level
of supervision; staff training, Supplies refers to medical and non-medical equipment/supplies
in the hospital, Clinical process of care refers to adherence to the standard operating procedures
for providing health care to patients, Patient safety refers to provision of health care which is
safe and minimises risks and harm to service users, Information sharing refers to the provider-
client information exchange for the purpose of diagnosis and the determination of preference
for treatment, Emotional support refers to the access to one’s own social and emotional support
and the psychosocial support given by the provider, Privacy refers to observance of patient’s
privacy from others at all time, Respectful care refers to the way provider treats his/her patients
throughout the process of care. The additional sub-themes are defined as Promptness refers to
how quickly the care is provided; reducing delays in providing care, Cleanliness refers to the
general cleanliness maintained in the hospital, Informal payment refers to the incidences of
providers asking for payment including cash; in-kind or any kind of gifts under the table. The
analytical framework also guided the tool development.
Study setting
The observations were conducted across nine public health facilities in two districts of UP, in
northern India. UP is the most populous state of India, but has some of the poorest health indi-
cators. UP has the second highest Maternal Mortality Ratio (MMR) and the third highest neo-
Quality of maternal care during childbirth in India
PLOS ONE | September 27, 2018 3 / 20
natal mortality rate (NMR) in the country, 285 and 49 respectively [35], compared to 167 [36]
and 28 at the national level [37]) respectively. The study districts of Kanpur Nagar and Unnao
were purposively selected for ease of access as both are neighbouring the state capital, Luck-
now. Kanpur Nagar has a high proportion of urban population (65.83%) while Unnao has
much lower urbanization (17.1%) and is primarily a rural district [38,39]. Of the two, Kanpur
Nagar fairs relatively better on the MCH indices with 76% institutional deliveries (69% in
Unnao) and 79% deliveries assisted by skilled personnel (71% in Unnao) when compared to
the state averages of 68% and 70% respectively [4042].
Study sites
A list of all public health facilities (CHCs and PHCs) with similar levels of care were obtained
and a total of nine facilities were randomly selected. These facilities were previous sites of a
Fig 1. Analytical framework of QoC themes for facility-based maternity care across five stages of child birth. Broad themes of
care ‘structure’ and ‘process’ in the analytical framework have been informed by Donabedian’s Quality framework. The WHO
framework with its eight domains of quality of care informed the sub-themes. Three additional emerging sub-themes emerging from
the data were included. The analytical framework was used for data analysis and guided the tool development. Abbreviation: QoC
Quality of Care.
Quality of maternal care during childbirth in India
PLOS ONE | September 27, 2018 4 / 20
large scale maternal health trial for the implementation of WHO Safe Childbirth Checklist. A
list of range of primary and secondary level facilities was included with an attempt to under-
stand providers’ and system-level challenges specific to both levels and ensure heterogeneity in
the data for wider implications. [S1 Table]
Study facilities ranged from 4–30 bed units, 2–3 delivery tables; all labour rooms had elec-
tricity with backup; 5 out of 9 labour rooms had a functional new born stabilization unit. Fil-
tered potable water and hospital meals were being provided in two and four health facilities
respectively. With respect to the availability of human resources across facilities there were
about a minimum of 1 to a maximum of 5 Lady Medical Officers; 4 to 9 staff nurse and ANMs
and 1 to 3 other support staff like sweeper in position. The patient load for vaginal deliveries in
the month of September 2016 ranged from as low as 110 to 257 with an average of 179 deliver-
ies being conducted across the centres.
Study instruments
A pre-tested facility observation checklist was used to capture women’s experience of labour
and delivery care at five different stages of delivery care—Admission; Pre-Delivery/Initial
Examination; Delivery; Post-Delivery and Discharge. The checklist, adapted from national
public health standards and maternal and newborn health guidelines. The checklist was not
pre-validated and had 114 items describing the normal sequence of actions that would follow
at every stage of institutional delivery as per the Indian standards of care [4345]. Checklist
items reflected the content (technical competency of provider, availability of supplies etc.) as
well as the process (information shared, emotional support, promptness) with a focus on ele-
ments of quality of person-centred care [S2 Table]. For instance to understand the process of
care a checklist item inquired about whether initial examination was done within 15 minutes
after registration; woman told how far along she was in labour; woman face any abuse during
labour etc. The observer could enter yes/no for every observation point, in addition to docu-
menting open-ended comments about significant observations regarding quality of care that
would support in understanding the case in greater detail.
Data collection
Data was collected by a four member team of two clinically trained nurses and two social sci-
entists. The nurse focused on the clinical aspect whereas the social scientists were capturing
person centred aspect of care. Prior to data collection, the investigators were trained on the
technique of direct, non-participant observation, checklist contents and expected details to be
captured. Training included practice observations using the checklist, on which the senior
researchers gave feedback to improve quality and depth of data recorded. The investigators vis-
ited each facility for a period of 4–5 consecutive days to conduct the observations. The team
was stationed at the facility from morning to evening; eight night-time deliveries were also
observed. Data collection at each facility was initiated by a formal introduction with the Medi-
cal Officer In-charge (MOIC) to explain the purpose of the project and brief the MOIC about
the intended data collection plan. This was followed by a facility tour for familiarization with
the staff and facility layout.
Informed verbal consent was obtained from all relevant staff prior to data collection. In
order to minimize inherent biases of observation on provider behaviour (Hawthrone effect),
one to two observations were conducted without formal recording, however there is a possibil-
ity of researcher bias as observations of behaviour are subjective in nature. To reduce this effect
a team of two trained nurses and two social scientists were asked to conduct observation for
each case simultaneously and later the observation checklist was matched for any marked
Quality of maternal care during childbirth in India
PLOS ONE | September 27, 2018 5 / 20
discrepancy. The providers were assured that data collection was anonymous and individual
performance would not be reported or published. In order to minimize changes to specific
aspects of behaviour, the providers were briefed broadly about the overall observation proce-
dure without sharing details of individual checklist items.
Pregnant women and their attendants visiting the facility for childbirth were randomly
approached and the purpose of the observation was explained to them in a manner that other
people present in the room could not listen to the conversation. Informed verbal consent was
then taken from participating women (and family members in some cases) prior to starting
the observation. A door-to-door approach was followed, meaning the same woman was
observed at all five stages of delivery care from admission through discharge. Each observation
lasted for about 8 to 12 hours and the same woman was followed until the end of the day and
the observation continued the next day to capture the discharge procedure. There were no
refusals, though there were a few cases where women had to be dropped from the observation
process, as they were referred out of the facility. In two emergency situations the investigators
had to intervene in order to assist the staff with arranging for the delivery.
At the end of each day, the entire research team discussed and completed a final checklist
after comparing data from individual checklists and coming to a consensus on final data
points. Open-ended comments from all four members were carefully included in the final
checklist. The completed and approved paper-based checklists were transferred to soft-form
by the study team.
Ethical approval and consent to participate. This study obtained ethical approval from
the University of California, San Francisco (153312) and the Institutional Ethics Committee of
the Public Health Foundation of India (TRC-IEC-276/15). In which the study received ethics
committee approval for obtaining verbal consent. Verbal consent was documented in a partici-
pant log maintained by the observation team. A written permission from the State Mission
Director, National Health Mission was obtained for undertaking the study in the selected facil-
ities. Approval was also taken from the Chief Medical Officers of the two districts before com-
mencing data collection.
Based on our analytical framework, data from the checklist was organized under the two broad
themes (structure and process) and then further categorized into sub-themes including: infra-
structure; human resource; supplies; clinical process of care; patient safety; information shar-
ing; emotional support; respectful care and privacy. Additional sub-themes (informal
payment, promptness and cleanliness) emerging from the observations were also identified
and included in the framework. Percentage observations for each checklist item were calcu-
lated using MS Excel 2010 which are discussed here as ‘few’ (below 25%); some (25–49%);
many (50–74%) and most (above 74%). Content from open-ended comments and notes sec-
tion of all the checklists was thoroughly reviewed and indexed using the study framework.
Narratives from the observations reflecting critical quality gaps across different stages of deliv-
ery care were also identified and presented as case-studies.
Results and discussions
The results are organized under two broad domains of quality, specifically ‘structure’ and ‘pro-
cess’ for each of the five stages of care during childbirth. The first domain (‘structure’) encom-
passes the organizational aspects of care: infrastructure; supplies and human resource. The
second domain (‘process’) describes the behavioural and technical aspects of care: promptness,
emotional support, information sharing, clinical process of care, patient safety; cleanliness,
Quality of maternal care during childbirth in India
PLOS ONE | September 27, 2018 6 / 20
informal payments and privacy. We describe the process of care across five stages from admis-
sion to discharge for all the 23 cases.
Stage 1: Admission
A uniform admission procedure was followed across all nine facilities. The staff nurses on duty
at the maternity unit were responsible for admission or referral of the women on the basis of
preliminary physical examination. Women reaching the facility for delivery were usually
accompanied by a Community Health Worker (CHW) and one or more relatives. The labour-
ing women were taken straight to the labour room, where the nurse conducted a physical
examination and determined whether the baby could be delivered at the facility or needed
referral to a higher level facility. In the meantime, male attendant(s) (usually a husband), was
directed to the registration counter located in the common admission area of the facility to
obtain a registration slip. At night, the nurse issued the registration slip, as the registration
counter was closed. In cases of referrals, a referral slip was provided; a mandatory written con-
sent from the husband was obtained and an ambulance was arranged.
No wheel chair or stretcher was available for taking most women into the maternity unit
and in few cases they had to be carried by their companions. The first physical examination
included measuring cervical dilation, time of contraction and determining position of the foe-
tus. While taking medical history, most providers also enquired about onset of labour and
membrane rupture. As per the Government of India’s Maternal and Newborn Health national
guidelines for all women in labour (cervix 4 cm) plotting contractions, Fetal Heart Rate
(FHR), maternal pulse, color of amniotic fluid every 30 mins; plotting temperature, blood
pressure and cervical dilation in cms every 4 hours is recommended. Although blood pressure,
FHR was measured for some women however, pulse and body temperature were not measured
even once for majority of the cases. The waiting time for admission for most women did not
exceed 15 minutes. None of the women or companions were asked for informal payments at
this stage.
Stage 2: Pre-delivery
The second observation stage spanned from the time the women were admitted to the mater-
nity unit until they were shifted to the labour room for delivery. The examination took place in
the labour room as there was no separate examination room in maternity units of any facility.
The maternity unit in all facilities had a common ward for prenatal, as well as postnatal
women. Most women spent close to 6–7 hours or more in the maternity unit prior to delivery.
During this period, women were mostly observed walking around, squatting or sitting on the
floor in the lobby area outside the labour room. In the event that a woman needed to rest, she
would use the beds in the postnatal (PNC) ward.
Monitoring the progress of labour was limited to conducting cervical dilation exam ranging
from once (in the first one hour) to a maximum of four times prior to delivery. Most of the
times the providers were called to check the progression when the woman faced increasing
pain or contractions. Only a few providers washed their hands and cleaned the woman’s peri-
neum before conducting vaginal examination. None of the providers were observed maintain-
ing partograph or any record of labour progression and instead relied on cervical dilation
exam also called the ‘two finger test’/’per vaginal’ test. Close to half the women observed were
not monitored at all prior to delivery, after the first physical examination at the time of admis-
sion. After performing cervical dilation exam, providers briefly informed women and compan-
ions about how long it would take for the delivery to happen. Providers ensured partial privacy
of women during physical examination as all examinations were performed in the labour
Quality of maternal care during childbirth in India
PLOS ONE | September 27, 2018 7 / 20
room. Though screens were available in labour rooms of most facilities, they were not being
used for maintaining inter-patient privacy. Most women were accompanied by at least one
female companion during the initial examination, who stayed with them during the pre-deliv-
ery stage. However, in a few cases women were left alone and unattended for periods longer
than 15 minutes prior to delivery. None of the women or companions were asked for informal
payments prior to delivery. Box 1 reflects to the poor clinical process of care being provided to
pregnant woman in one of the facilities under study.
Stage 3: Delivery
The third stage of observation was that of the delivery. Only a few women had to wait for more
than 15 minutes before being shifted to the labour room once they were ready for delivery
(fully dilated). It was observed that majority of the labour rooms had two to three delivery
tables and well-equipped with power back-up to enable night time deliveries during power
cuts. Most deliveries were performed by the staff nurse, assisted by one or more staff and the
CHW. In addition to the CHW, all providers allowed at least one female birth companion with
the women during delivery who could be the mother/mother-in-law or sister/sister-in-law.
Companions of nearly half of the women were asked to purchase medicines (mostly oxytocin)
and other supplies from nearby pharmacies located outside the facility. These included, syrin-
ges, blade, sanitary pads, soap and cloth for wiping the woman and her baby. Delivery of each
woman was conducted on a separate delivery table. Almost all providers supported normal
delivery by providing perineum support and good coaching in terms of emotional, physical
and informational support, resulting in few episiotomies, however only a few women were
allowed to deliver in the position they desired. The providers in most cases did not help the
women climb onto or get down from the delivery table and mostly supported by her compan-
ions. Some women were left unattended for more than 15 minutes in the labour room.
With regard to patient safety, providers in nearly all cases used sterile surgical gloves for
examining the women, though only in a few cases they performed hand hygiene prior to that.
In many cases blades (used for cutting the umbilical cord) were reused after washing in bleach-
ing solution. Other instruments were washed under running water and seldom soaked in
decontamination solution after use. Delivery tables were wiped after each delivery was per-
formed with the cloth brought by the women without use of any disinfectant. Most providers
disposed the contaminated waste in leak-proof containers. However, all sharps were either left
on the table or thrown on the floor, to be cleared by the sweeper later on, while the women
were still lying on the delivery table.
Box 1. Clinical process of care
After conducting the previous delivery, the nurse was on the terrace (open area next to
the maternity unit). Meanwhile, the woman (already present on the terrace) started
vomiting profusely and within no time laid flat on the ground and delivered the baby.
The nurse came running and said: “why didn’t you tell me; I am standing here
only. . .you fool!” The baby kept lying on the floor for about 2 mins, after which the
nurse and sweeper brought the supplies. CHW and Mother-in-law were standing beside
the woman but none of them picked up the baby from the floor. The sweeper held the
baby, cleaned it with a cloth, and placed the baby on the mother’s abdomen. After which
she clamped and cut the cord using a blade, and the nurse gave an oxytocin injection to
the woman.
Quality of maternal care during childbirth in India
PLOS ONE | September 27, 2018 8 / 20
As per the Government of India’s Maternal and Newborn Health national guidelines 10 IU
of oxytocin IM must be administered within 1 minute of birth for normal labour and delivery.
However, in half of the cases women were administered a uterotonic (oxytocin 1ml to 3 ml)
prior to delivery for inducing labour pains and all injections were given without disinfecting
the skin. The umbilical cord was clamped using a sterile clip in case of most deliveries. Imme-
diate uterine massage was given to most women following delivery of placenta. Assessment for
complete removal of placenta and membranes, as well as for perineal and vaginal lacerations
was not carried out for close to half of the cases. Likewise, immediate postpartum care includ-
ing taking vital signs, administering antibiotics and palpating the uterus was not performed
for more than half of the cases. Most women were not exposed unnecessarily at any point dur-
ing delivery.
Most babies were wiped and covered using a piece of cloth brought by the women’s fami-
lies; the nose and mouth were cleaned using the same cloth. The birth weight was recorded
either immediately or at a later time for most babies delivered. Immediate skin-to-skin contact
was established for close to two-thirds deliveries. Most providers did not check baby’s temper-
ature within 15 minutes of birth.
A few women were physically and verbally abused (talking roughly, pushing, pulling, slap-
ping on thigh) by the providers including assistant staff, in the process of delivery. For instance
pulling/pushing the woman on the delivery table for adjusting position; shouting at her and/or
slapping on the thigh when the woman doesn’t seem to follow the instructions given by the
provider; giving undue fundal pressure; ask her to go to some other hospital if not willing to
follow provider’s instructions. This would generally happen in spite of the presence of the
companions and ASHA worker. A few instances of demand for informal payments were also
observed, where the staff asked for money before handing the baby to the women and their
companions. Box 2: reflections pointing to an instance of informal payment being demanded
from the woman’s family before handing the baby to the mother.
Table 1 lists the important indicators performed by the providers during procedure and
post-procedure for all the 23 cases that were observed across all nine facilities.
Stage 4: Post- delivery
The fourth stage of observation spanned from the time the women were shifted to the PNC
ward until their discharge. In all cases women were kept under observation in the labour room
for 45 to 60 minutes after delivery. They were examined for bleeding and shifted to the PNC
ward, once their condition was stable. During this time the companions would arrange for tea
and snacks (mainly biscuits) for the women and staff. The PNC stay for most women ranged
from 6–10 hours in case of day time deliveries and up to 24 hours in case of late night
Box 2. Informal payment
The nurse placed the baby on the weighing machine uncovered and un-wiped and
demanded money from the mother-in-law (MIL). The MIL placed 25 INR on the
machine but the nurse was not happy with it and said: “are you not ashamed of offering
such a low amount of money to me?” Then the MIL placed 10 INR more and said: “we
are poor people and we have only this much to offer.” The nurse got angry and left the
baby and money on the machine and left the room saying: “I don’t need this money. If
you are poor then keep this money as you will need it”.
Quality of maternal care during childbirth in India
PLOS ONE | September 27, 2018 9 / 20
deliveries. The PNC ward of most facilities was located close to the nurse duty room and facili-
tated monitoring of women in the ward.
PNC wards in all the facilities were equipped with beds, electricity (with backup), toilets
and drinking water supply mostly hand-pumps. There was no restriction on the number of vis-
itors or companions allowed inside the PNC ward, often making the ward too crowded during
visiting hours. The presence of male visitors in the PNC ward impeded privacy during breast-
feeding. Although all women and babies got a separate bed during their stay in the PNC ward,
there was no arrangement for companions, who either shared the bed with the women or slept
on the floor. The bed cots and bedsheets were clean in almost half of the facilities. However,
toilets were found to be dirty and the light fixtures were often missing or faulty. Hospital meals
for the women were available in close to half of the facilities.
Staff worked in shifts of 10–24 hours, ensuring that at least one staff member (Nurse/Skilled
Birth Attendant/Doctor) was available in the maternity unit most of the time. Close to half of
the women were visited by a nurse or doctor at least once during their stay. The examination
was limited to verbal enquiry of general condition of the baby and mother, and checks of
blood pressure and postpartum bleeding. Only some women received counselling on essential
postnatal care that focused mainly on exclusive breastfeeding, immunization and family plan-
ning. The number of women counselled for danger signs of mother’s and baby’s health were
very few. A few women faced verbal abuse (talking roughly) during the postnatal period. Few
providers were seen demanding informal payments. Box 3: reflections pointing to an instance
of poor post-delivery newborn care provided to one of the cases being observed.
Table 1. Clinical and non-clinical indicators: Direct observation of women (N = 23) in study facilities.
Stages Indicators
Pre- Delivery 1. Initial examination done within 15 minutes after registration (Most)
2. Provider evaluate blood pressure (Some); pulse (Few); temperature (Few)
3. Provider evaluate test for glucose in urine (None)
4. Provider evaluate test for haemoglobin (None)
5. Determine position of fetus (Most)
6. Determine fetal Heart rate (Some)
7. Care provider wash hands before examination (Few)
8. Cleaning of woman’s perineum before examination (Few)
9. Woman’s privacy maintained during the physical examination (Many)$
10. Woman informed about labour progression (Many)$
11. Have to wait at the observation ward (Many)$
Delivery 12. Women left alone at any point (Some)$
13. Use box of sterile instruments for each delivery (Some)
14. Monitoring of labour-Record keeping in partograph (None)
15. Motivated woman to push the baby (Most) $
16. Administers uterotonic (All); before delivery (Many); after delivery (Many)
17. Performs uterine massage immediately following the delivery of the placenta (Many)
18. Someone present during delivery to provide support (All) $
19. Woman face any abuse during labour (Few) $
20. Takes mother’s vital signs 15 minutes after birth (Some)
21. Palpates uterus 15 minutes after delivery of placenta (Some)
22. Disposal of all contaminated waste in leak-proof containers (Most)
23. Disinfect cord (Most)
24. Immediate skin-to-skin contact (Many)
-Non Clinical indicators.
The table lists critical clinical and non-clinical indicators performed by providers for all 23 cases that were observed.
These have been classified as ‘None (0%); few (below 25%); some (25–49%); many (50–74%); most (above 74%) and
all (100%) and discussed under two stages of—pre-delivery and delivery.
Quality of maternal care during childbirth in India
PLOS ONE | September 27, 2018 10 / 20
Stage 5: Discharge
The fifth stage of observation was the discharge process, in which the women filled the Janani
Suraksya Yojna form to claim their financial incentive. At the time of discharge the staff usu-
ally vaccinated the babies, counselled the women on postnatal care and dispensed medicines.
Across facilities, the staff nurse completed most of the discharge formalities except JSY paper
work and arrangement for transport, which was done by the CHWs. A few women were coun-
selled at their bed side. All others were counselled in the nurse duty room while the baby was
being vaccinated. The counselling mainly focused around immunization; family planning and
exclusive breastfeeding. Identifying the baby’s and mother’s danger signs was the least dis-
cussed topic. Most women and their companions were given information on the immuniza-
tion schedule, whereas only some of them received instructions for follow-up check-ups. Close
to half of the women did not receive free medicines and cotton/sanitary pads at the time of dis-
charge. Informal payments were demanded from a few women at the time of discharge.
This paper describes the findings of the quality of maternity care provided in primary and sec-
ondary level public health facilities in two districts of UP, India. Direct, non-participant obser-
vations were used to capture the critical components of both clinical as well as non-clinical
obstetric care from admission through discharge. Door-to-door observation of the entire jour-
ney of a woman’s experience of delivery care allowed identification of critical gap areas specific
to each of the five stages. Few other studies have similar in-depth documentation [22,27,46
48]. These studies were conducted in similar settings—Ethiopia; Nigeria; UP and MP in India
and most of them used direct observations of intrapartum care provided during labour and
childbirth except one in Nigeria that employs a different qualitative approach to capture the
experiences of providers and women. Good practices, as well as gaps, were observed at each
stage of delivery care. Most gaps were noted during delivery and pre-delivery stage, most strik-
ingly on patient safety and the clinical process of care. Overall, though human resources and
infrastructure were available across all facilities, five key areas of concern were identified: inad-
equate clinical care and patient safety, information sharing, compromised privacy, disrespect-
ful care and informal payments.
Box 3. Post- delivery care
It was a breech baby. The baby was born with some deformity in the feet and did not cry
soon after birth therefore the nurse started the resuscitation process. The baby was
shifted to the Newborn Stabilization Unit and was placed in a baby warmer. The nurse
started reviving the baby with the help of ambubag. She tried to inject 5 ml calcium glu-
conate mixed in 5 percent dextrose in the cord of the baby but the cord clip was clamped
too close to the navel of the baby leaving no space for injecting the drug. When injecting
the drug through the cord failed, the doctor (on emergency duty) advised for injecting
the drug via catheter. It took almost close to 10 minutes for the nurse to find a surgical
tape before preparing a catheter opening, which also did not work. Next, the team
started aspiration using mucus extractor. The baby could not be revived and seeing the
baby unresponsive the doctor decided to refer the baby to the nearby district hospital
but soon the baby died. After completing the final investigation the doctor informed the
family and mother about death of the baby.
Quality of maternal care during childbirth in India
PLOS ONE | September 27, 2018 11 / 20
Table 2 summarizes key good practices and areas of concern noted in the observations
across five stages of delivery care. Most gaps were identified during the ‘delivery stage’. ‘Clini-
cal process of care’ and ‘patient safety’ during pre-delivery and delivery stages were the key
areas of concern where gaps were noticed in the quality of care provision. Gaps were observed
in other areas of care provision that included information sharing, maintaining privacy, pro-
viding emotional support and demanding informal payment. Structural gaps—infrastructure
and human resource provision were not as startling as the areas included in the ‘process’ of
First, there were a number of gaps in clinical process of care. Study findings suggest that
routine monitoring of labour such as use of partograph, fetal heart rate monitoring, blood
pressure, temperature and pulse rate were not being performed by all providers uniformly.
Providers in some cases administered uterotonic prior to delivery for inducing labour pains
[49,50], which is not consistent with national and global guidelines [51]. Similarly, some of
the essential care practices during third stage of labour and immediate post-partum period like
controlled cord traction, palpation of uterus, and assessment for perineal and vaginal lacera-
tions, were not performed for most cases. This has also been observed in other studies [5254].
According to a hospital-based cross-sectional study conducted in Netherland the active third
stage management was being adequately performed in only close to half of all vaginal deliveries
[54]. Other gaps include inappropriate maternal and newborn infection management, not pro-
viding immediate skin to skin contact and no assessment of newborn’s health [22,46,55].
Gaps in patient safety included providers not performing hand hygiene before wearing sterile
gloves, instruments not being sterilized; and improper disposal of sharps. Similar evidence has
been found in other studies conducted in India [22,55,56].
Lack of information, privacy, and emotional support were the other key gap areas in the
process of care. Patient-provider interaction and information sharing was limited in terms of
content, quantity and quality. Establishing a two-way communication with the woman, mak-
ing her a receptive and active participant in improving the process of care, is often a neglected
aspect of delivery care provision [28,57,58]. Other studies in conducted in Malawi and Haiti
have observed sharing inadequate information on postpartum care, specially information on
danger signs [59,60]. In terms of maintaining privacy, though entry of males was restricted in
all labour rooms, use of drapes and screens for providing privacy to the labouring women was
not practiced, corroborating findings from other studies [27,29]. Findings from a five country
study conducted in health facilities in Africa points out women experiencing compromised
auditory and visual privacy resonating well with our findings [27].
Recent reports from many low- and middle–income countries suggest that women are
being denied labour companionship, especially during childbirth [27,28]. However, we did
not find any such restrictions in our study and our findings were consistent with other studies
in India [18,29]. All women were allowed to have at least one female companion along with
the CHW throughout labour and delivery. Several studies have highlighted women experienc-
ing abandonment and neglect during childbirth [29,61,62]. Our study also found that some
women were left unattended in the delivery room after childbirth for more than 15 minutes.
Although few in number, there were instances of women experiencing both verbal and physi-
cal abuse at the hands of the provider, mostly during labour and delivery. Similar experiences
of disrespectful maternal care including pushing, slapping, shouting, threatening women for
refusal to treatment, and unwarranted fundal pressure have been reported in studies from
other developing countries including India [22,27,28,61].
Informal payments was also a concern in these facilities. JSY guarantees women delivering
at any government institution free delivery care along with monetary incentives. However,
research has highlighted issues of informal payments and other out-of-pocket expenditure
Quality of maternal care during childbirth in India
PLOS ONE | September 27, 2018 12 / 20
Table 2. Summary of areas of concern and good practices observed in the study.
Themes of care Good practice Areas of concern
Infrastructure Admission
Signboards showing registration counter; Ramp way clear; defined
waiting area with seating arrangement; drinking water and power
supply (with backup)
Adequate beds and delivery tables
Adequate beds available for all women and babies
Free transport for home arranged
No stretcher or wheelchair provided to take women to labour room.
Adequate seating and sleeping arrangements not available for companions
Human Resource Delivery
All deliveries conducted by skilled provider (mostly staff nurse)
Security guard not present to regulate visitors in PNC ward
Supplies - Delivery
Family members arranged for medicine/cotton
Women did not receive medicines; pads/cotton
Clinical Process
of Care
Sterile surgical gloves used for examination of most women
Incomplete initial examination—blood pressure; pulse; temperature;
hemoglobin and glucose in urine and fetal heart rate not conducted for
close to half of the women
Partograph not filled during and after delivery
Administration of uterotonic (oxytocin 1ml to 3 ml) prior to delivery—
inducing labour pains
Skin not disinfected before giving injection;
Perineal and vaginal lacerations not assessed;
Vital signs not taken 15 minutes after delivery;
Uterus not palpated 15 minutes after delivery of placenta;
Immediate skin-to-skin contact not established
Vaginal packing and giving unwarranted fundal pressure (Most cases)
For most babies, temperature and skin color not monitored 15 minutes
after birth and vitamin K not administered
Lining the uterus with mustard oil before delivery (Few cases)
Cleaning the baby’s body and inside of the mouth with mustard oil (Few
Keeping the baby uncovered until cord cutting and weighing (Few cases)
While using the mucus extractor Mothers asked to suck from one end
while inserting the tube in baby’s mouth and nostrils (Few cases)
No examination conducted (including blood pressure) and most babies
were not examined in PNC ward
Patient Safety Delivery
Disposal of all contaminated waste in leak-proof containers Pre-delivery
Hand hygiene and cleaning women’s perineum before examination
nearly absent
Using condom for conducting per vaginal examination (Few cases)
Used gloves left on the delivery table close to the patient (Few cases)
Hand hygiene not performed before any examination; sharps not
disposed properly and immediately after use; sterile supplies (gloves,
cotton; blade; tray) not used for some deliveries
The broken (used) oxytocin vials were thrown on the floor
Quality of maternal care during childbirth in India
PLOS ONE | September 27, 2018 13 / 20
negating the benefit of the monetary incentive provided by the state [14,30,6365]. While we
observed that informal payments were demanded in a few cases, it is possible that the extent of
informal payment demanded by the staff is underreported since our presence may have altered
their behavior. We also found that providers in many facilities also insisted that patients and
their families purchase drugs from private pharmacies located close to the facility, though sup-
plies were available in most facility.
Over the past years there has been a growing pool of evidence from across the globe sug-
gesting that until a satisfactory level of quality is attained in service delivery, the desired and
Table 2. (Continued)
Themes of care Good practice Areas of concern
Women were told how far they were in labour
Women or family members not able to ask question to the providers
Information about mother’s and baby’s health not shared with
Counseling on breastfeeding and thermal care not provided
Danger signs not discussed
Women were not counselled on family planning; immunization; exclusive
breast feeding; baby’s and mother’s danger sign and instructions for follow-
up check-ups not given
Female companions allowed in labour room
Companions stayed throughout in the PNC ward
No support in helping women climb on the delivery table;
Women left alone in the delivery room post-delivery for more than 15
Privacy Delivery
Most women not exposed unnecessarily during delivery
Dividing screen/curtain between delivery tables not available in labour
Male visitors were present in the PNC ward at all times
Respectful Care - Delivery
Women faced verbal and/or physical abuse during labour (few cases)
Promptness Pre-delivery
PV and abdominal examination conducted within 15 minutes of
reaching the facility for all women
Women were kept under observation in labour room for more
than an hour before shifting to PNC ward
JSY paper work completed before discharge
Women not visited by provider at least once in three hours
Cleanliness - Post-delivery
Cots/bed sheets were not clean
Toilets and bathrooms not clean
No provider asked for informal payment
Providers asked for money to the accompanied person (few cases)
Out-of-pocket expenditure for services including medicines; informal
payment; photograph for JSY (few cases)
Abbreviations: PV Per Vaginal; PNC Post Natal Car; JSY Janani Suraksha Yojana
The table lists ‘good practices’ and key ‘areas of concern’ as per the Indian Public Health Standards guidelines for Primary and Community health centres, 2012. These
have been discussed under five stages of delivery care—admission; pre-procedure; procedure; post-procedure and discharge and further categorized into themes of
quality care framework.
Quality of maternal care during childbirth in India
PLOS ONE | September 27, 2018 14 / 20
expected reductions in maternal mortality cannot be achieved only by improving infrastruc-
ture, accessibility and incentivizing institutional delivery [22,33,66]. In India, the current
quality assurance guidelines have shifted focus from not only ensuring facility infrastructure,
but also addressing measures to ensure patient privacy, increasing patient information and
engagement, and setting up a system of grievance redress in the form of Patient Welfare Com-
mittee [18]. Our findings have the following policy implications in order to make the health
system more outcome driven and responsive to patient’s needs, aspects such as promptness,
information sharing and respectful behaviour need to be incorporated in the policies [32,33].
Studies have highlighted that challenges deterring optimal utilization of facilities includes lack
of adherence to clinical protocols; compromised patient safety; women-friendly delivery envi-
ronment; cognitive support; compromised privacy; frequent abuse and demand for informal
payments [22,29]. Identifying and addressing structural gaps, training and orientation of staff
towards aspects of person-centered care, and adherence to clinical protocols through crite-
rion-based audits needs to be prioritized and implemented [33,67]. Training and orientation
of staff towards aspects of person-centred care including respectful & supportive care; infor-
mation sharing; effective communication skills and patient privacy can go a long way in sensi-
tizing providers around person-centred care, supported by public display of behavioural
norms in the charter of patient rights and entitlements. The findings from a quality improve-
ment (QI) intervention in public health facilities across six states of India, suggest that simple
QI methods like redesign of space and task shifting have the potential to improve quality of
facility-based routine clinical practices in resource poor settings like India [62] QI cycles may
be followed by performance based grading of facilities on attainment of specific quality bench-
marks to encourage adoption of good care practices. A concept of ‘positive deviance approach’
may also be introduced for collating and sharing ‘best practices’ with regards to quality of care
in facilities performing better while having access to the same resources and facing similar or
worse challenges.
One of the key limitations common to observational studies is that staff actions may have been
influenced by the presence of the observers. To minimize this bias, the investigators spent a
day in the facility familiarizing themselves with the setting and interacting with the staff before
beginning to record the observations. We assumed that this would put the staff at ease with the
team by the time the observations began; however, we acknowledge this potential bias remains.
The second limitation of the observation method is the observer’s bias in data collection and
interpretation of results. We worked to mitigate this by using a standardized checklist to
record the data across the team and triangulating the findings of multiple observers.
It is encouraging to witness developing countries like India slowly realizing the need and
importance of improving quality of care in public health facilities in order to make care more
responsive to women’s needs. Findings from this study reflect gaps in the ‘quality front’ of
maternity care provision in public health facilities in India and our results support the argu-
ment for strengthening maternity care services provided by the public health system.
Identifying and addressing structural gaps including infrastructure and medical supplies
should be prioritized [34], followed by gaps related to ‘process of care’ including clinical care;
patient safety; information sharing; emotional support; informal payments; and disrespectful
care. Staff training is required on aspects of person-centered care such as therapeutic commu-
nication. Clinical supervision of staff; criterion-based audits; near-miss audits; and supportive
Quality of maternal care during childbirth in India
PLOS ONE | September 27, 2018 15 / 20
supervision should be undertaken for ensuring adherence to clinical care protocols and quality
norms [34,67]. There is evidence that simple Quality Improvement methods like redesigning
of space and task shifting have the potential to improve quality of facility-based routine clinical
practices in resource-poor settings like India [62]. Appreciating positive deviance and recog-
nizing quality of care ‘best practices’ could also encourage facilities to optimize quality within
the given resources.
Supporting information
S1 Table. Profile of study facilities by provider and infrastructure provision. Acronyms:
CHC-Community Health Centre; PHC-Primary Health Centre; BPHC-Block Primary Health
Centre; FRU-First Referral Unit; ANM-Auxiliary Nurse Midwife. Source:
data and departmental Health Management Information System (HMIS) records, Sep 2016.
Description of data: The table gives information about profile of the study facilities including
facility type; number of in-position staff in the maternity unit; available infrastructure facilities
and patient load for vaginal and caesarean deliveries for the month of September 2016.
S2 Table. Checklist for facility observation.
We would like to acknowledge the contributions of the participating investigators—May Sud-
hinaraset; Nadia Diamond Smith; Katie Giessler and Dominic Montagu in performing techni-
cal editing of the manuscript; Mousumi Gogoi for participating in data collection and data
curation; Tanuja Mehra, Nidhi Pandey and Ruchi Yadav for participating in data collection.
Author Contributions
Conceptualization: Aradhana Srivastava, Sanghita Bhattacharyya.
Data curation: Malvika Saxena, Aradhana Srivastava.
Formal analysis: Malvika Saxena, Aradhana Srivastava, Sanghita Bhattacharyya.
Investigation: Malvika Saxena, Pravesh Dwivedi.
Methodology: Aradhana Srivastava, Sanghita Bhattacharyya.
Project administration: Pravesh Dwivedi.
Supervision: Aradhana Srivastava, Sanghita Bhattacharyya.
Visualization: Aradhana Srivastava, Sanghita Bhattacharyya.
Writing – original draft: Malvika Saxena, Aradhana Srivastava, Sanghita Bhattacharyya.
Writing – review & editing: Malvika Saxena, Aradhana Srivastava, Pravesh Dwivedi, Sanghita
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... The EMEN assessment tool was developed by pulling together the best interventions of WHO's Service Availability Readiness Assessment (SARA) and those used in vigorous research settings (9). By using the tool to collect data, we were able to capture gaps in quality of care identified in other large studies (9,(18)(19)(20) and across the WHO/UNICEF quality framework (Supplementary Figure S1 and Table S3). This demonstrates the strong validity and reliability of the EMEN tool and the results of this study. ...
... This resulted in low/poor postpartum and postnatal newborn care within evidence-based care standard 1 or the first domain, while the second domain includes low/poor providerclient information sharing or communication and low/poor women involvement in decisions and actions taken about their care. Our results are similar to the findings from past studies (9,(18)(19)(20)26) conducted in Bangladesh, Ghana, Tanzania, Kenya, and India that used mixed methods and direct observation. ...
... Depending on the mother's level of education on danger signs and how far they live from the nearest health facility, newborns may be at risk of preventable deaths due to delay in seeking care or late identification of the condition. This result is consistent with an Indian study where few newborns were examined in the postnatal ward (18). ...
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Background Quality of care around childbirth can reduce above half of the stillbirths and newborn deaths. Northeast Namibia’s neonatal mortality is higher than the national level. Yet, no review exists on the quality of care provided around childbirth. This paper reports on baseline assessment for implementing WHO/UNICEF/UNFPA quality measures around childbirth. Methods A mixed-methods research design was used to assess quality of care around childbirth. To obtain good saturation and adequate women opinions, we purposively sampled the only high-volume hospital in northeast Namibia; observed 53 women at admission, of which 19 progressed to deliver on the same day/hours of data collection; and interviewed 20 staff and 100 women who were discharged after delivery. The sampled hospital accounted for half of all deliveries in that region and had a high (27/1,000) neonatal mortality rate above the national (20/1,000) level. We systematically sampled every 22nd delivery until the 259 mother–baby pair was reached. Data were collected using the Every Mother Every Newborn assessment tool, entered, and analyzed using SPSS V.27. Descriptive statistics was used, and results were summarized into tables and graphs. Results We reviewed 259 mother–baby pair records. Blood pressure, pulse, and temperature measurements were done in 98% of observed women and 90% of interviewed women at discharge. Above 80% of human and essential physical resources were adequately available. Gaps were identified within the WHO/UNICEF/UNFPA quality standard 1, a quality statement on routine postpartum and postnatal newborn care (1.1c), and also within standards 4, 5, and 6 on provider–client interactions (4.1), information sharing (5.3), and companionship (6.1). Only 45% of staff received in-service training/refresher on postnatal care and breastfeeding. Most mothers were not informed about breastfeeding (52%), postpartum care and hygiene (59%), and family planning (72%). On average, 49% of newborn postnatal care interventions (1.1c) were practiced. Few mothers (0–12%) could mention any newborn danger signs. Conclusion This is the first study in Namibia to assess WHO/UNICEF/UNFPA quality-of-care measures around childbirth. Measurement of provider–client interactions and information sharing revealed significant deficiencies in this aspect of care that negatively affected the client’s experience of care. To achieve reductions in neonatal death, improved training in communication skills to educate clients is likely to have a major positive and relatively low-cost impact.
... Despite the adequate funding, our study identified delays in funding disbursement, a low capacity for budgeting and planning, and poor civil registration skills. Inadequate water supply, unclean or non-functional essential infrastructure, such as a clean toilet and sink, were seen in our study, reflecting a low institutional commitment to improving conditions in postnatal wards and consistent with previous research ( Saxena et al., 2018 ;Tristanti et al., 2019 ). ...
... Involving family in health education was limited though there were many opportunities. Our findings are similar to previous studies in India, Tanzania, and -the United Kingdom that reported limited contact between health workers and mothers in the postnatal ward and very little counselling on danger signs ( Dol et al., 2019 ;Hunter et al., 2015 ;Saxena et al., 2018 ). This is a missed opportunity since the period staying in the postnatal ward is probably the only contact these rural mothers and their families will have with health workers for the first two months of the babies' life. ...
Objective: This study examined routine newborn care practices provided in the postnatal ward of primary health care facilities, known as Puskesmas, in Sikka District of eastern Indonesia The newborn mortality rate in this region is higher than the national rate despite an increasing proportion of facility based births, suggesting suboptimal quality of newborn care. Design: We employed a mixed methods study combining qualitative and quantitative approaches, in four purposively sampled Puskesmas. Nine mothers, twelve midwives, and four key informants were interviewed on the provision and experience of postnatal care, and an audit of postnatal care processes, including observation of routine postnatal check-up was conducted. The data were analyzed using framework analysis and standard descriptive statistics. Findings: Despite appropriate regulation, national guidance on postnatal care and adequate financing that supported continuity of supplies and equipment, postnatal care practices, including counselling around newborn danger signs, did not meet the national guidelines in any of the Puskesmas in this study. Postnatal care was a low priority, the responsibility often given to new graduates on voluntary placements with little job security, who were insufficiently trained or supervised. In addition, inadequate water and sanitation in postnatal care wards deterred women from staying for the recommended postnatal observation period. Conclusion: Despite strong support for postnatal care at the policy level, at the implementation level postnatal newborn care is not prioritised by midwives. Under-functioning infrastructure and inadequate planning and budgeting for postnatal check-ups are major challenges to the provision of care in the postnatal wards.
... Various studies have pointed out that in the most resource-limited settings, many patients share labor rooms. [63][64][65] In such environments, women experience exposure to other patients, male visitors, and staff who are not attending to them as undignified, inhumane, or shameful. 7 Studies from South Asian and African countries also report that women experience compromised auditory and visual privacy, which resonates with our findings. ...
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Introduction: Respectful maternity care (RMC) during childbirth is an integral component of quality of care. However, women's experiences of mistreatment are prevalent in many low- and middle-income countries. This is a complex phenomenon that has not been well explored from a behavioral science perspective. We aimed to understand the behavioral drivers of mistreatment during childbirth among maternity care staff at public health facilities in the Sindh province of Pakistan. Methods: Applying the COM-B (capability-opportunity-motivation that leads to behavior change) model, we conducted semistructured in-depth interviews among clinical and nonclinical staff in public health facilities in Thatta and Sujawal, Sindh, Pakistan. Data were analyzed using thematic deductive analysis, and findings were synthesized using the COM-B model. Results: We identified several behavioral drivers of mistreatment during childbirth: (1) institutional guidelines on RMC and training opportunities were absent, resulting in a lack of providers' knowledge and skills; (2) facilities lacked the infrastructure to maintain patient privacy and confidentiality and did not permit males as birth companions; (3) lack of provider performance monitoring system and patient feedback mechanism contributed to providers not feeling appreciated or recognized. Staff bias against patients from lower castes contributed to patient abuse and mistreatment. The perspectives of clinical and nonclinical staff overlapped regarding potential drivers of mistreatment during childbirth. Conclusions: Addressing mistreatment during childbirth requires improving the knowledge and capacity of maternity staff on RMC and psychosocial support to enhance their understanding of RMC. At the health facility level, governance and accountability mechanisms in routine supervision and monitoring of staff need to be improved. Patients' feedback should be incorporated for continuous improvement in providing maternity care services that meet patients' preferences and needs.
... Saxena et al. [22] discovered a lack of clinical care, abuse events, and unofficial payment demands, which were found in the present study. Participants expressed the need for support during labor pains, and there should not be any money requests after childbirth, timely care, and they expect welcomed behavior from staff, which was reported in a study by Kyaddondo et al. [23] In a similar study published in 2019 by Sharma et al., [12] it was discovered that workers received informal remuneration for delivering treatment. ...
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Background: Many women face disrespectful and abusive treatment during childbirth in facilities worldwide. Such treatment violates women's rights to respectful care and jeopardizes their rights to life, health, bodily integrity, and equality. This study aims at identifying the status of respectful maternity care (RMC) in selected hospitals in Rishikesh. Material and Methods: A mixed-method approach was adopted to explore RMC during normal vaginal delivery in a selected hospital in Rishikesh, Uttarakhand. In the quantitative part, 145 women were purposively selected, and data were collected by a pre-structured, validated RMC checklist, developed based on WHO RMC standards. Qualitative data were collected from 18 women, and a face-to-face semi-structured interview was conducted. Results: Forty-two elements of RMC categorized under eight domains show the type of mistreatment and its prevalence faced by women at a health care facility. Data showed that domain-7 (availability of competent and motivated human resources) had higher scoring (95%), and on the other hand, domain-4 (informed consent and effective communication) got lowest-scoring (68.45%). The overall mean percentage score of RMC was 85.68%. There was no statistically significant association between the total score of RMC and the selected socio-demographic variables. Conclusion: The overall RMC score was high, and there was no significant association with mothers' socio-demographic variables. The majority of mothers expressed that competent and motivated professionals were available during their delivery, but their communication skills were found to be lacking.
... We achieved data saturation for each participant category (31). The code frequencies were grouped as follows: "None" (0%); "Few" (below 25%); "Some" (25-49%); "Many" (50-74%); "Most" (75-99%); and "All" (100%) (37). "Quotable quotes" were identified from the responses. ...
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Introduction The COVID-19 pandemic disrupted newborn care and breastfeeding practices across most healthcare facilities. We undertook this study to explore the barriers and enablers for newborn care and breastfeeding practices in hospitals in Delhi, India for recently delivered mother (RDM)–newborn dyads during the first wave of the COVID-19 pandemic (2020) and inductively design a “pathway of impaction” for informing mitigatory initiatives during the current and future pandemics, at least in the initial months. Materials and methods We used an exploratory descriptive design (qualitative research method) and collected information from seven leading public health facilities in Delhi, India. We conducted separate interviews with the head and senior faculty from the Departments of Pediatrics/Neonatology ( n = 12) and Obstetrics ( n = 7), resident doctors ( n = 14), nurses (labor room/maternity ward; n = 13), and RDMs ( n = 45) across three profiles: (a) COVID-19-negative RDM with healthy newborn ( n = 18), (b) COVID-19-positive RDM with healthy newborn ( n = 19), and (c) COVID-19 positive RDM with sick newborn needing intensive care ( n = 8) along with their care-giving family members ( n = 39). We analyzed the data using grounded theory as the method and phenomenology as the philosophy of our research. Results Anxiety among clients and providers, evolving evidence and advisories, separation of the COVID-positive RDM from her newborn at birth, providers' tendency to minimize contact duration and frequency with COVID-positive mothers, compromised counseling on breastfeeding, logistic difficulties in expression and transportation of COVID-positive mother's milk to her baby in the nursery, COVID restrictions, staff shortage and unavailable family support in wards and nursery, and inadequate infrastructure were identified as major barriers. Keeping the RDM–newborn together, harmonization of standard operating procedures between professional associations and within and between departments, strategic mobilization of resources, optimization of human resources, strengthening client–provider interaction, risk triaging, leveraging technology, and leadership-in-crisis-situations were notable enablers. Conclusion The separation of the RDM and newborn led to a cascade of disruptions to newborn care and breastfeeding practices in the study institutions. Separating the newborn from the mother should be avoided during public health emergencies unless there is robust evidence favoring the same; routine institutional practices should be family centered.
... The quality of maternal care provided can vary [48]. Context is vital in health systems improvement interventions such as for handover [49]. ...
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Introduction Beyond the provision of services, quality of care and patient safety measures such as optimal clinical handover at shift changes determine maternity outcomes. We aimed to establish the proportion of women handed over and the content of clinical handovers and communication between shifts within 3 diverse obstetrics units in Kerala, India, and to describe the handover environment. Methods A cross sectional study was conducted for six weeks during February and March 2015at three hospitals in Kerala, India, during nurses obstetric handover in one tertiary private, one tertiary government and one secondary government hospital. Nursing handovers in obstetric post-operative, in-patient and labour wards were sampled. An SBAR-based (situation, background, assessment and recommendation) data schedule was completed whilst observing handover at nursing shift changes. Since obstetricians had no scheduled handover, qualitative interviews were conducted with obstetricians in two hospitals to establish how they acquire information when beginning a shift. Results Data was obtained on 258 patients handed over, within 67 shift changes. The median percentage of women handed over was 100% in two of the hospitals and 27.6% in the other. The median number of information items included out of a possible 25 was 11, 5 and 4,and did not change significantly for women with high-risk status. Important items regarding assessment and recommendation for care were often missed, including high-risk status. The median number of environment items achieved was good at 7 out of 10 in all hospitals. Obstetricians sought information in various ways when required. All supported the development of structured tools, face-to-face and team handovers. Conclusions Maternity unit handovers for doctors and nurses were inadequate. Ensuring handover of all women and including critical information, between shifts as well as between doctors, needs to be improved to increase patient safety.
... India has more than 80% hospital deliveries, and a slow declining Maternal Mortality Ratio (MMR) currently at 103 per 100,000 [16] and Stillbirth rate at 4 per 1,000 live births [17]. There was noted improvement in proportion of institutional deliveries [18,19], but the quality of childbirth services and referrals did not improve accordingly [20][21][22]. In recent years the Government of India has emphasised on strengthening infrastructure and quality of obstetric care through several programs [15,[23][24][25]. ...
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Background: Dakshata program in India aims to improve resources, providers’ competence and accountability in labour wards of public sector secondary care hospitals. It is based on the WHO Safe Childbirth Checklist coupled with mentoring. In Rajasthan state, an external technical partner trained, mentored and periodically assessed performance; identified local problems and supported solutions; supported state in monitoring. We (a third party) evaluated the effectiveness and factors contributing to success and sustainability. Methods: We conducted three repeat mixed-method surveys across 24 hospitals which were at different stage of program implementation when evaluation initiated: Group 1-trainings started and Group 2-one round of mentoring completed. We followed them over 18 months. Data was collected by directly observing obstetric assessments and childbirth, extracting information from casesheets and registers, and interviewing postnatal women. Theory-driven qualitative assessment included in-depth interviews with administrators, mentors, obstetric staff, and officers/mentors from external partner. Results: Average adherence to practices increased, saw a dip and then again improved. Significant improvement noted in several practices in the two groups—more in pause points 1, 2 and 3 but less in 4. Overall average adherence improved: Group 1, 55% to 72%; and Group 2, 69% to 79% (p<0.001). Stillbirth rate reduced: Group 1, 1.5/1,000 to 0.2; and Group 2, 2.5 to 1.1 (p<0.001). The mentoring with periodic assessments were highly acceptable, efficient means of capacity building, and ensured continuity in skills upgradation. Nurses felt empowered while involvement of doctors was low. The state health administration was highly committed and involved in program management; hospital administration supported. The competence, consistency and support from the technical partner were highly appreciated. Conclusion: Dakshata program was successful in improving resources and competencies. The program is sustainable and scalable. The states with low capacities will require intensive external support for a head start.
... This mismatch in demand and supply resulted in poor quality of care in terms of adherence to evidence-based intrapartum care practices and respectful maternal care provided to the laboring women. 10,11 Singh et al. reported that despite the increase in institutional deliveries, the maternal mortality ratio did not decline considerably. 12 Some studies have reported an increased maternal mortality ratio in tertiary care institutes due to delivery overload and poor quality of services rendered after delivery. ...
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Introduction: Implementation research with pre- and post-comparison was planned to improve the quality of evidence-based intrapartum care services in Indian medical schools. We present the baseline study results to assess the status of adherence to intrapartum evidence-based practices (IP-EBP) in study schools in 3 states in India and the perception of the faculty. Methods: A concurrent mixed-methods approach was used to conduct the baseline assessment in 9 medical schools in Rajasthan, Gujarat, and Union Territory from October 2018 to June 2019. IP-EBP among pregnant women in uncomplicated first (n=135), second (n=120), and third stage (n=120) of labor were observed using a predesigned, pretested checklist quantitatively. We conducted in-depth interviews with 33 obstetrics and gynecology faculty to understand their perceptions of intrapartum practices. Quantitative data were analyzed using SPSS (version 22). COM-B (Capability, Opportunity, and Motivation Behavior) model was used to understand the behaviors, and thematic analysis was done for the qualitative data. Findings: Unindicated augmentation of labor was done in 64.4%, fundal pressure applied in 50.8%, episiotomy done in 58.3%, and delivery in lithotomy position was performed in 86.7% of women in labor. Conclusions: Intrapartum practices that are not recommended were routinely practiced in the study medical schools due to a lack of staff awareness of evidence-based practices and incorrect beliefs about their impact.
... Our results indicate an overall negative satisfaction with staff maintaining confidentiality at the secondary & tertiary facilities in two states. A study by Saxena et al. in nine public health facilities in India also reported a lack of privacy to women in labour.32 ...
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Background: Patient satisfaction is an essential indicator for measuring the quality of care. This study assessed patients' satisfaction with primary care services across different public health care system levels. Methods: The study was a cross-sectional study conducted across three states in India. We adopted a multi-stage stratified random sampling technique to select the districts(n-13) and facilities (n-55). A total of 4650 patients' exit interviews were conducted. Linear regression and analysis of variance was used to test the association. Analyses was performed using Stata software (version 15.0). Results: Patients visiting the primary facilities were more satisfied within the different domains of quality indicators that is, technical, communication, safety and cleanliness, and cost of services. The highest differences were observed on behaviour of other staff (Reg Coefficient 4.1 ± 0.8) and cleanliness of the ward (Reg Coefficient 4.0 ± 0.9). Significant negative association was observed in patient's satisfaction in the state of Kerala with an increase in age and education level. Conclusion: Our study suggests higher satisfaction at primary care facilities as compared to secondary and tertiary level facilities in the three states. Development of standardized tool and specific research on patient experience and its relation to the quality of care is needed in low- and middle-income countries.
Birthing women require support, particularly emotional support, during the process of labour and delivery. Traditionally, across cultures, this support was made available by the continuous presence of a companion during labour, childbirth and the immediate post-partum period. However, this practice is not universal, especially in health facilities in low- and middle-income countries. This cross-sectional study was conducted in 18 tertiary health care facilities of India using a mixed-method approach. The quantitative data were collected to document the number of birthing women, birth companions and healthcare providers in the labour rooms, and the typology of disrespect and abuse (D&A) faced by women. This was followed by in-depth interviews with 55 providers to understand their perspective on the various dimensions of D&A and the challenges they face to provide respectful care. This article explores the status of birth companionship in India and its plausible associations with D&A faced by birthing women in public facilities. Our study reveals that birth companionship is still not a common practice in Indian public hospitals. Birth companions were present during less than half of the observational period, also less than half of the birthing women were accompanied by a birth companion. Lack of hospital policy, space constraints, overcrowding and privacy concerns for other patients were cited as reasons for not allowing birth companions in the labour rooms, whose supportive roles, both for women and providers, were otherwise widely acknowledged during the qualitative interviews. Also, the presence of birth companions was found to be critically negatively associated with occurrences of D&A of birthing women. We contend that owing to the high pressure on the public hospitals in India, birth companions can be a low-cost intervention model for promoting respectful maternity care. However, adequate infrastructure is a critical aspect to be taken care of.
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Background The study aims to assess the discordance between self-reported and observed measures of mistreatment of women during childbirth in public health facilities in Uttar Pradesh, India, as well as correlates of these measures and their discordance. Methods Cross sectional data were collected through direct observation of deliveries and follow-up interviews with women (n = 875) delivering in 81 public health facilities in Uttar Pradesh. Participants were surveyed on demographics, mistreatment during childbirth, and maternal and newborn complications. Provider characteristics (training, age) were obtained through interviews with providers, and observation data were obtained from checklists completed by trained nurse investigators to document quality of care at delivery. Mistreatment was assessed via self-report and observed measures which included 17 and 6 items respectively. Cohen’s kappas assessed concordance between the 6 items common in the self-report and observed measures. Regression models assessed associations between characteristics of women and providers for each outcome. ResultsMost participants (77.3%) self-reported mistreatment in at least 1 of the 17-item measure. For the 6 items included in both self-report and observations, 9.1% of women self-reported mistreatment, whereas observers reported 22.4% of women being mistreated. Cohen’s kappas indicated mostly fair to moderate concordance. Regression analyses found that multiparous birth (AOR = 1.50, 95% CI = 1.06–2.13), post-partum maternal complications (AOR = 2.0, 95% CI = 1.34–3.06); new-born complications (AOR = 2.6, 95% CI = 1. 96–4.03) and not having an Skilled Birth Attendant (SBA) trained provider (AOR = 1.47, 95% CI = 1.05–2.04) were associated with increased risk for mistreatment as measured by self-report. In contrast, only provider characteristics like older provider (AOR = 1.03, 95% CI = 1.02–1.05) and provider not trained in SBA (AOR = 1.44, 95% CI = 1.02–2.02) were associated with mistreatment as measured through observations. Younger age at marriage (AOR = 0.86, 95% CI = 0.78–0.95) and provider characteristics (older provider AOR = 1.05, 95% CI = 1.01–1.09; provider not trained in SBA AOR = 0.96, 95% CI = 0.92–0.99) were associated with discordance (based on mistreatment reported by observer but not by women). Conclusion Provider mistreatment during childbirth is prevalent in Uttar Pradesh and may be under-reported by women, particularly when they are younger or when providers are older or less trained. The findings warrant programmatic action as well as more research to better understand the context and drivers of both behavior and reporting. Trial registrationCTRI/2015/09/006219. Registered 28 September 2015.
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Background: Person-centered care is a critical component of quality care, essential to enable treatment adherence, and maximize health outcomes. Improving the quality of health services is a key strategy to achieve the new global target of zero preventable maternal deaths by 2030. Recognizing this, the Government of India has in the last decade initiated a number of strategies to address quality of care in health and family welfare services. Methods: We conducted a policy review of quality improvement strategies in India from 2005 to 15, covering three critical areas- maternal and newborn health, family planning, and abortion (MNHFP + A). Based on Walt and Gilson's policy triangle framework, we analyzed the extent to which policies incorporated person-centered care, while identifying unaddressed issues. Data was sourced from Government of India websites, scientific and grey literature databases. Results: Twenty-two national policy documents, comprising two policy statements and 20 implementation guidelines of specific schemes were included in the review. Quality improvement strategies span infrastructure, commodities, human resources, competencies, and accountability that are driving quality assurance in MNHFP + A services. However, several implementation challenges have affected compliance with person-centered care, thereby affecting utilization and outcomes. Conclusion: Focus on person-centered care in Indian MNHFP + A policy has increased in recent years. Nevertheless, some aspects must still be strengthened, such as positive interpersonal behavior, information sharing and promptness of care. Implementation can be improved through better provider training, patient feedback and monitoring mechanisms. Moreover, unless persisting structural challenges are addressed implementation of person-centered care in facilities will not be effective.
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Objective To evaluate the quality of essential care during normal labour and childbirth in maternity facilities in Uttar Pradesh, India. Methods Between 26 May and 8 July 2015, we used clinical observations to assess care provision for 275 mother–neonate pairs at 26 hospitals. Data on 42 items of care were collected, summarized into 17 clinical practices and three aggregate scores and then weighted to obtain population-based estimates. We examined unadjusted differences in quality between the public and private facilities. Multilevel linear mixed-effects models were used to adjust for birth attendant, facility and maternal characteristics. Findings The quality of care we observed was generally poor in both private and public facilities; the mean percentage of essential clinical care practices completed for each woman was 35.7%. Weighted estimates indicate that unqualified personnel provided care for 73.0% and 27.0% of the mother–neonate pairs in public and private facilities, respectively. Obstetric, neonatal and overall care at birth appeared better in the private facilities than in the public ones. In the adjusted analysis, the score for overall quality of care in private facilities was found to be six percentage points higher than the corresponding score for public facilities. Conclusion In 2015, the personnel providing labour and childbirth care in maternity facilities were often unqualified and adherence to care protocols was generally poor. Initiatives to measure and improve the quality of care during labour and childbirth need to be developed in the private and public facilities in Uttar Pradesh.
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Background Disrespect and abuse of women during institutional childbirth services is one of the deterrents to utilization of maternity care services in Ethiopia and other low- and middle-income countries. This paper describes the prevalence of respectful maternity care (RMC) and mistreatment of women in hospitals and health centers, and identifies factors associated with occurrence of RMC and mistreatment of women during institutional labor and childbirth services. Methods This study had a cross sectional study design. Trained external observers assessed care provided to 240 women in 28 health centers and hospitals during labor and childbirth using structured observation checklists. The outcome variable, providers’ RMC performance, was measured by nine behavioral descriptors. The outcome, any mistreatment, was measured by four items related to mistreatment of women: physical abuse, verbal abuse, absence of privacy during examination and abandonment. We present percentages of the nine RMC indicators, mean score of providers’ RMC performance and the adjusted multilevel model regression coefficients to determine the association with a quality improvement program and other facility and provider characteristics. Results Women on average received 5.9 (66%) of the nine recommended RMC practices. Health centers demonstrated higher RMC performance than hospitals. At least one form of mistreatment of women was committed in 36% of the observations (38% in health centers and 32% in hospitals). Higher likelihood of performing high level of RMC was found among male vs. female providers (\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$ \widehat{\beta}=0.65 $$\end{document}β^=0.65, p = 0.012), midwives vs. other cadres (\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$ \widehat{\beta} = 0.88 $$\end{document}β^=0.88, p = 0.002), facilities implementing a quality improvement approach, Standards-based Management and Recognition (SBM-R©) (\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$ \widehat{\beta}=1.31 $$\end{document}β^=1.31, p = 0.003), and among laboring women accompanied by a companion \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$ \widehat{\beta} = 0.99 $$\end{document}β^=0.99, p = 0.003). No factor was associated with observed mistreatment of women. Conclusion Quality improvement using SBM-R© and having a companion during labor and delivery were associated with RMC. Policy makers need to consider the role of quality improvement approaches and accommodating companions in promoting RMC. More research is needed to identify the reason for superior RMC performance of male providers over female providers and midwives compared to other professional cadre, as are longitudinal studies of quality improvement on RMC and mistreatment of women during labor and childbirth services in public health facilities.
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Objective To know and understand the perspectives of women on the quality of maternal health services provided at their health facility (HF) and to incite community self-propelled problem identification and way forward. Methods A qualitative action- oriented research was conducted in a rural setting in Tanzania from 2011 to 2014. Twenty In-Depth Interviews (IDIs) and two Focus Group Discussions were held. The IDIs were conducted with mothers who had attended antenatal care at the HF and delivered there. The recordings transformed into English texts were used for analysis to get themes and possible explanations that were compared and reflected. Results More than half 60% of the respondents reported to have experienced abuse by the health staff, 80% reported lack of amenities and all agreed to unavailability of health services at odd hours or weekends. Conclusion and Global Health Implications This study reveals that the quality of maternal health services provided at the HF is not up to standard. The study demonstrates the importance of self-diagnosis in a community and to propel self-community interventions towards improving rural health services. The government, researchers and other stakeholders have key roles in the elimination of health disparities and unhealthy political mingling in health care.
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Background While increase in the number of women delivering in health facilities has been rapid, the quality of obstetric and neonatal care continues to be poor in India, contributing to high maternal and neonatal mortality. Methods The USAID ASSIST Project supported health workers in 125 public health facilities (delivering approximately 180,000 babies per year) across six states to use quality improvement (QI) approaches to provide better care to women and babies before, during and immediately after delivery. As part of this intervention, each month, health workers recorded data related to nine elements of routine care alongside data on perinatal mortality. We aggregated facility level data and conducted segmented regression to analyse the effect of the intervention over time. ResultsCare improved to 90–99% significantly (p < 0.001) for eight of the nine process elements. A significant (p < 0.001) positive change of 30–70% points was observed during post intervention for all the indicators and 3–17% points month-to-month progress shown from the segmented results. Perinatal mortality declined from 26.7 to 22.9 deaths/1000 live births (p < 0.01) over time, however, it is not clear that the intervention had any significant effect on it. Conclusion These results demonstrate the effectiveness of QI approaches in improving provision of routine care, yet these approaches are underused in the Indian health system. We discuss the implications of this for policy makers.
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Background Despite improvement, maternal mortality in Haiti remains high at 359/100,000 live births. Improving access to high quality antenatal and postnatal care has been shown to reduce maternal mortality and improve newborn outcomes. Little is known regarding the quality and uptake of antenatal and postnatal care among Haitian women. Methods Exit interviews were conducted with all pregnant and postpartum women seeking care from large health facilities (n = 10) in the Nord and Nord-Est department and communes of St. Marc, Verrettes, and Petite Rivière in Haiti over the study period (March-April 2015; 3–4 days/facility). Standard questions related to demographics, previous pregnancies, current pregnancy, and services/satisfaction during the visit were asked. Total number of antenatal visits were abstracted from charts of recently delivered women (n = 1141). Provider knowledge assessments were completed by antenatal and postnatal care providers (n = 39). Frequencies were calculated for descriptive variables and multivariable logistic regression was used to explore predictors of receiving 5 out of 10 counseling messages among pregnant women. ResultsAmong 894 pregnant women seeking antenatal care, most reported receiving standard clinical service components during their visit (97% were weighed, 80% had fetal heart tones checked), however fewer reported receiving recommended counseling messages (44% counselled on danger signs, 33% on postpartum family planning). Far fewer women were seeking postnatal care (n = 63) and similar service patterns were reported. Forty-three percent of pregnant women report receiving at least 5 out of 10 counseling messages. Pregnant women on a repeat visit and women with greater educational attainment had greater odds of reporting having received 5 out of 10 counseling messages (2nd visit: adjusted odds ratio [aOR] =1.70, 95% confidence interval [CI]: 1.09–2.66; 5+ visit: aOR = 5.44, 95% CI: 2.91–10.16; elementary school certificate: aOR = 2.06, 95% CI: 1.17–3.63; finished secondary school or more aOR = 1.97, 95% CI = 1.05–3.02). Chart reviews indicate 27% of women completed a single antenatal visit and 36% completed the recommended 4 visits. Conclusions Antenatal and postnatal care uptake in Haiti is sub-optimal. Despite frequent reports of provision of standard service components, counseling messages are low. Consistent provision of standardized counseling messages with regular provider trainings is recommended to improve quality and uptake of care in Haiti.
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Background Global efforts have increased facility-based childbirth, but substantial barriers remain in some settings. In Nigeria, women report that poor provider attitudes influence their use of maternal health services. Evidence also suggests that women in Nigeria may experience mistreatment during childbirth; however, there is limited understanding of how and why mistreatment this occurs. This study uses qualitative methods to explore women and providers’ experiences and perceptions of mistreatment during childbirth in two health facilities and catchment areas in Abuja, Nigeria. Methods In-depth interviews (IDIs) and focus group discussions (FGDs) were used with a purposive sample of women of reproductive age, midwives, doctors and facility administrators. Instruments were semi-structured discussion guides. Participants were asked about their experiences and perceptions of, and perceived factors influencing mistreatment during childbirth. Thematic analysis was used to synthesize findings into meaningful sub-themes, narrative text and illustrative quotations, which were interpreted within the context of this study and an existing typology of mistreatment during childbirth. ResultsWomen and providers reported experiencing or witnessing physical abuse including slapping, physical restraint to a delivery bed, and detainment in the hospital and verbal abuse, such as shouting and threatening women with physical abuse. Women sometimes overcame tremendous barriers to reach a hospital, only to give birth on the floor, unattended by a provider. Participants identified three main factors contributing to mistreatment: poor provider attitudes, women’s behavior, and health systems constraints. Conclusions Moving forward, findings from this study must be communicated to key stakeholders at the study facilities. Measurement tools to assess how often mistreatment occurs and in what manner must be developed for monitoring and evaluation. Any intervention to prevent mistreatment will need to be multifaceted, and implementers should consider lessons learned from related interventions, such as increasing audit and feedback including from women, promoting labor companionship and encouraging stress-coping training for providers.
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Background Reducing maternal morbidity and mortality remains a key health challenge in Guinea. Anecdotal evidence suggests that women in Guinea are subjected to mistreatment during childbirth in health facilities, but limited research exists on this topic. This study was conducted to better understand the social norms and the acceptability of four scenarios of mistreatment during childbirth, from the perspectives of women and service providers. Methods This study used qualitative methods including in-depth interviews (IDIs) and focus group discussions (FGDs) with women of reproductive age, midwives, nurses and doctors. This study was conducted in one urban area (Mamou) and one peri-urban area (Pita) in Guinea. Participants were presented with four scenarios of mistreatment during childbirth, including a provider: (1) slapping a woman; (2) verbally abusing a woman; (3) refusing to help a woman; and (4) forcing a woman to give birth on the floor. Data were collected in local languages (Pular and Malinké) and French, and transcribed and analyzed in French. We used a thematic analysis approach and manually coded the data using a codebook developed for the project. Results A total of 40 IDIs and eight FGDs were conducted with women of reproductive age, 5 IDIs with doctors, and 13 IDIs with midwives. Most women were not accepting of any of the scenarios, unless the action was perceived to be used to save the life of the mother or child. However, they perceived a woman’s disobedience and uncooperativeness to contribute to her poor treatment. Women reacted to this mistreatment by accepting poor treatment, refusal to use the same hospital, revenge against the provider or complaints to hospital management. Service providers were accepting of mistreatment when women were disobedient, uncooperative, or to save the life of the baby. Conclusions This is the first known study on mistreatment of women during childbirth to be conducted in Guinea. Both women and service providers were accepting of mistreatment during childbirth under certain conditions. Any approach to preventing and eliminating mistreatment during childbirth must consider these important contextual and social norms and develop a comprehensive intervention that addresses root causes. Further research is needed on how to measure mistreatment during childbirth in Guinea.
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Background India accounts for 27 % of world’s neonatal deaths. Although more Indian women deliver in facilities currently than a decade ago, early neonatal mortality has not declined, likely because of insufficient quality of care. The WHO Safe Childbirth Checklist (SCC) was developed to support health workers to perform essential practices known to reduce preventable maternal and new-born deaths around the time of childbirth. Despite promising early research many outstanding questions remain about effectiveness of the SCC in low-resource settings. Methods In collaboration with the Ministry of Health SCC was modified for Indian context and introduced in 101 intervention facilities in Rajasthan, India and 99 facilities served as comparison to study if it reduces mortality. This Quasi experimental Observational intervention-comparison was embedded in this larger program to test whether a program for introduction of SCC with simple implementation package was associated with increased adherence to 28 evidence-based practices. This study was conducted in 8 intervention and 8 comparison sites. Program interventions to promote appropriate use of the SCC included orienting providers to the checklist, modest modifications of the SCC to promote provider uptake and accountability, ensuring availability of essential supplies, and providing supportive supervision for helping providers in using the SCC. Results The SCC was used by providers in 86 % of 240 deliveries observed in the eight intervention facilities. Providers in the intervention group significantly adhered to practices included in the SCC than providers in the comparison group controlling for baseline scores and confounders. Women delivering in the intervention facilities received on an average 11.5 more of the 28 practices included compared with women in the comparison facilities. For selected practices provider performance in the intervention group increased as much as 93 % than comparison sites. Conclusion Use of the SCC and provider performance of best practices increased in intervention facilities reflecting improvement in quality of facility childbirth care for women and new-born in low resource settings.